The effort to expand Medicaid in Kansas fell apart Monday as the House failed to override Gov. Sam Brownback’s veto of a bill that would have expanded the health care program to thousands of low-income people in the state.

The 81-44 vote, three shy of the 84 needed to overcome the governor’s opposition, effectively ends the Medicaid expansion push in Kansas after it successfully passed both chambers with bipartisan support earlier this year.

That was then. This is now. Kansas now has a Democratic governor who supports Medicaid expansion, and yesterday this happened (via Jim McLean of the Kansas News Service):

The Centers for Medicare & Medicaid Services has approved a waiver request for work requirements in Ohio’s Medicaid program.

...CMS rolled out guidance on these waivers in January 2018, and since then eight states, including Ohio, have had requests approved. Several additional states have submitted waivers that the agency has yet to weigh in on.

...Arkansas is the only state where such work requirements have formally been launched, and in the last several months of 2018, more than 18,000 people lost Medicaid coverage as a result of the work requirement. The Kaiser Family Foundation estimated that most of these losses were a result of the administrative requirements associated with reporting work hours.

Access Health CT, Connecticut's state-based ACA exchange, released their 2019 Open Enrollment Period report, and it's one of the most extensively detailed & granual looks at the year's enrollment data. They've included the normal stuff, of course (subsidized vs. unsubsidized, metal levels, age and income brackets, etc)...but they've also done a very deep dive into data points I haven't seen before by cross-indexing categories.

For instance, not only did they break out "enrollment attrition reasons" (that is, why 2018 enrollees who didn't renew their policies chose not to), but they actually broke that out into what those enrollees' financial assistance status was.

The level of detail here is pretty impressive and somewhat overwhelming (there's 25 pages of charts & graphs), but if you're a healthcare nerd interested in what's going on in the Nutmeg State, knock yourself out!

DENVER – Coloradans who get financial help buying health insurance through Connect for Health Colorado® are paying an average 14 percent less in “net premium” – what they pay after assistance – compared to the average net premium in 2018, according to data released today.

Three of every four current Connect for Health Colorado customers qualify for financial help to reduce the monthly cost of health insurance. The average net premium for those Coloradans is $117 per month, down from $136 per month last year.

“We are happy that we are able to make health insurance affordable for so many people,” said Kevin Patterson, Chief Executive Office of Connect for Health Colorado. “The number of our customers receiving help rose this year by seven percentage points, to 76 percent, an important increase. We know we have more work to do, and are committed to expanding our impact as we work with policy makers, our stakeholders and our customers throughout the state.

In light of the flurry of state-level legislation locking in ACA protections in New Mexico and Maine over the past few weeks, this seems like a good point to check in on other states as well.

One more time: Here's what the ACA's "3-Legged Stool" looks like as of March 2019. The Trump Administration and Congressional Republicans tried to sabotage the Green Leg by cutting off Cost Sharing Reduction reimbursement payments...but the insurance carriers mostly cancelled this out by Silver Loading. The end result of this is that the federal government is actually shelling out up to $20 billion more in APTC subsidies per year, more than cancelling out the $10 billion or so they're saving in unpaid CSR costs (and they may still have to pay that as well anyway!)

Last week I noted that New Mexico had capped off a flurry of positive healthcare policy legislation by passing a bill (in dramatic fashion) which would lock in ACA-level protections for those with pre-existing conditions in the event the ACA itself is ever repealed or weakened.

Once this bill is signed by the Governor (which is almost certain to happen), New Mexico will join four other states (Massachusetts, New York, Colorado and Virginia) in fully protecting all three types of "blue leg" protections: Guaranteed Issue, Community Rating and Essential Health Benefits. The New Mexico bill also locks in a fourth ACA protection: The prohibition on annual or lifetime coverage limits.

The CSR Lawsuit Saga has been a continuous rollercoaster ride since 2014 at this point, with the original lawsuit (brought by John friggin' Boehner) seeing twists including one of the plaintiffs becoming one of the named defendents, and the named defendent changing at least three times as the Trump Administration went through several HHS Secretaries over the course of a few months.

NOT hurting the very people he was trying to hurt (low-income enrollees);

HURTING the very people he supposedly wasn't trying to hurt (middle-income enrollees), and as an added bonus...

INCREASING federal spending by a projected $20 billion dollars per year in increased premium subsidies

Nearly 100 insurance carriers who were stiffed by Trump out of a couple billion dollars owed to them for 2017 sued the federal government, and the judges in the cases ruled in their favor, ordering the feds to pay up. This much was completely expected and not at all out of the ordinary.

When it comes to discussing changes in healthcare policy, one of the most important--and most frustrating--topics which have to be tackled is how much healthcare services actually cost. I'm not necessarily talking about how much the patient pays, although that's obviously important as well...I'm referring to how much the healthcare providers charge and get paid.

Doctors, hospitals, clinics, pharmaceutical companies, medical device makers and so forth all get paid different amounts for different services from different payors, depending on whether it's a private insurance carrier, Medicare or Medicaid...and those rates generally range widely from state to state and carrier to carrier. One partial exception to this is Maryland, where they've been experimenting fairly successfully with a concept called "all-payer" rate setting:

*("major" is obviously a subjective term depending on who's using it.)

Until this weekend, "Medicare for All or Bust" seemed to be the most critical litmus test for any major 2020 Democratic Presidential candidate. No fewer than sixteen Democratic Senators co-sponsored Bernie Sanders' S.1804 "Medicare for All" single payer bill in September 2017, including five of the six U.S. Senators currently running for the 2020 nomination: Sanders himself, Cory Booker, Kirsten Gillibrand, Kamala Harris and Elizabeth Warren (the only Senator running who didn't cosponsor the bill was Amy Klobuchar.)

Recently, however, there have been a few interesting developments along the "Where do the Dem candidates stand on healthcare policy" front:

In the 5 1/2 years that I've been operating this website (has it really been that long?), I was surprised (pun intended) to realize that out of the 5,600+ blog entries that I've posted, only 2-3 have mentioned "Surprise Bills" (also known as "Balance Billing", although I think there are some differences between the two):

The state Senate gave initial approval Wednesday to a Senate bill that would allow small-business employers to offer an association health-insurance plan, or AHP, that could provide lower premium costs.

Senate Bill 86 received a 40-8 vote on second reading, but an objection to a third reading kept it on the Senate calendar until at least today.

The GOP holds a majority in the NC Senate, but only by 29 to 21, so stopping this there was apparently a lost cause. They also hold a 65 to 54 majority in the state House. I'm not sure whether SB 86 has already been voted on there or not. If it passes both, it would be up to Democratic Governor Roy Cooper to veto the bill.

Over the past year or so, ever since Donald Trump issued an executive order re-opening the floodgates on non-ACA compliant "short-term, limited duration" (STLD) healthcare policies (otherwise known as "junk plans" since they tend to have massive holes in coverage and leave enrollees exposed to financial ruin in many cases), numerous states have passed laws locking in restrictions on them or, in a few cases, eliminating them altogether:

Arthur Childs, DO, FACOI is an internist specializing in critical care medicine in Cape May Court House*, New Jersey. About a year ago, as part of a project for the Jefferson School of Population Health, he put together his own Strategic Roadmap for Healthcare Delivery in the United States as a potential alternative to the various universal coverage proposals being tossed around on the left side of the aisle these days. He asked me to read it over and wanted my feedback.

I've done so, and while I'm still a strong proponent of going the Medicare for America route, he makes a lot of useful points and provides much food for thought. It's also very well-researched and cited, and I felt it deserved a wider audience. And so, with the permission of both him and the Jefferson School of Population Health, I'm presenting his full paper with a few of my own thoughts interspersed.

(sigh) Well, it was a good run while it lasted. As I noted last week, New Mexico's new Democratic trifecta government has been on something of a tear in the first few months of 2019, either passing or advancing a number of positive healthcare policies, including:

In addition, there was one more important piece of legislation which looked like it was going to go through without too much fuss: HB 436, which would simply lock in protections for New Mexico residents with pre-existing conditions at the same level that the Affordable Care Act already does nationally: